This ain't 1991.

Do you ever have these moments where you want to fix everything? I mean, fix the things that could potentially be fixable if you and like a whole, whole, whole bunch of people galvanized to make it better?

Yeah. Like that.

I have feelings like that a lot. Sometimes it's a really big and nebulous thing. Other times, it's more concrete and smallish. That is, until I really start to flesh it out. So then I'm just sort of left with this problem that I think I may have some ideas to help with solving. But simultaneously this tiny undercurrent of angst because I'm not.

Sigh. This sounds rambly, doesn't it? Like, I'm sure someone is like, "She goes a bunch of weeks without blogging and this is what she posts?" Or maybe that's too self-important a position to take. Perhaps you, too, are busy and don't fully give a shit whether or not I blog every day or every month but still think this sounds cryptic and tangential.

Okay. Fair enough. I guess I'll give an example of my latest "thing" that I'm thinking about (in terms of problems that need solutions.) And since you already can see that I'm feeling rambly, I advise you to read at your own risk of utter confusion.

Yeah.

Okay. So check it: 1991 was the year I applied to medical school. I drove to Auburn, Alabama from Tuskegee, Alabama and took the MCAT on my 21st birthday. I remember that part well because on my way home, I stopped at the State Store and bought a pint of some kind of alcoholic beverage. Not so much because I wanted to get drunk, but more because I could buy a pint of something--using my legit state-issued over-twenty-one identification, that is. Anyways. Luckily, I did pretty well on it on that first go (the MCAT, not the pint of liquor.) That fall, I began hammering out my med school applications for what I hoped would be my future career.

Yup.

Now. 1991 was a hell of a lot different than 2016. See, back then, you literally "hammered" out applications--on a typewriter. Sure did. I typed my applications out and mailed them via snail mail. Yes. Via the United States Postal Service. Some human received my envelope, tore it open with a letter opener, and read it. They looked at my picture and read my personal statement. My letters were skimmed and my meaningful participation in student leadership was noted. And all of that was coupled with my academic performance and MCAT scores for a more complete picture of my potential as a medical student at their institution.

I got plenty of interviews. And though I was a good candidate in terms of merit, I wasn't necessarily out-of-this-world academically. But coupled with my total package of service and leadership? I was a very attractive potential med student--if I do say so myself.

Yep.

But this? This is totally, totally different than the way things are now. Now? Everything is electronically-based. Applications are just a few clicks away and one universal form goes everywhere. That means it's easier to to apply to more schools. And for the schools, it means way more applicants from way more places.

Now that? That part isn't really a big deal and is probably a good thing mostly. But what is tricky is that now that it's computer based coupled with more volume, that human-being-looking-at-the-real-you component is removed. Or, at least, super diminished. That is, unless you jump the first objective academic merits hurdle--then, and only then, will your chances of getting your stuff looked at become highest. Which makes it MUCH harder to get into medical school (or any super competitive school without a slam dunk GPA, MCAT and, just maybe, alma mater.

Oh--and let me clarify something on the alma mater part: A 3.9 GPA from anywhere? You're golden. A 3.5 is more complicated. That said, that 3.5 GPA will be looked at differently if it is from Princeton or Harvard. I mean, it just will. Does it mean you have to go to an Ivy League school to get into medical school? Definitely not. And would I trade my HBCU undergraduate experience for anything in the whole world? No way. But it's probably fair to say that certain schools might get a person more wiggle room than others in the numbers game.

Okay. So here's why I'm talking about this: There's not a month that goes by that I don't receive an email, in box message or call from a friend, a family member, a friend of a family member or even just some acquaintance-of-an-acquaintance asking me to speak with someone who is applying to medical school. Now. If they are young? Like a freshman or even a first semester sophomore? It's great. Really, it is. But usually, that isn't who the person is.

Nope.

Often it's someone who is a college senior or who has already graduated. Maybe they look like me, but not always. But what does seem to be very common is that there is this critical information that they needed long before the call was made to me that they never received. And that information is simple:

This ain't 1991.

It breaks my heart to hear someone say their GPA from non-sexy state university or teeny-tiny-college-that-we've-heard-of but-the-admissions-committee-hasn't was "pretty good" and that they "could've done better on the MCAT." So I ask, of course, what "pretty good" means. That's when I learn that usually that's anything from a 3.0 to a 3.4 cumulative grade point average. Which, I know, I know, to a lot of folks reading this sounds great. And to me, I'd agree that this would sound totally great--were this 1991.

But, it ain't. Nope.

See now? Now with it all computer based, the easy clicks that you used to apply with less difficulty are also happening on the admissions end. A few mouse clicks helps medical schools easily filter out the "pretty goods" from the academically exceptional ones. GPA under 3.5? Click. MCAT under 505? Click. So the fact that you were SGA president or a volunteer at the Humane Society or a dancer with the Alvin Ailey Dance theater before college? Sorry about that. Thanks to your academic numbers, I'll never see it. Or your lovely headshot that your mom helped you narrow down and select.

Nope.

So yeah. I find myself hearing these earnest young people and feeling like a damn dream killer. I listen and make a few suggestions but deep down what I really want to say is, "You need to go back to your freshman year and start over. You need to be pressed to get a great GPA from day one, especially if you went to a school that isn't the first ones people roll off of their tongues when listing the very top-tiered institutions of higher learning."

That brings me to this solution. The solution would be for a bunch of doctors to go to colleges--particularly some of our smaller ones --- and talk to freshman from the very start. We need to show up and give that speech that Debbie Allen gave the kids at the Performing Arts High School during their first days.

"You want to go to med school? Well med school costs. And right here is where you start paying. In sweat." 

And honestly? I'm not even joking. That message needs to reach aspiring doctors waaaaaay before they cross into their junior or senior year of college. The caveat, of course, is if you already were knocking it out of the park all along. Then there isn't such an urgency.

But what's messed up is that a 3.4 GPA is really not bad at all, man. It isn't. But for medical school? It pretty much sucks. Unless, of course, you know someone somewhere who can help open a few doors or you have your sights set on less competitive schools. But remember--even those schools now have more applicants in their pool due to the click-click-click culture, remember? And a lot of folks are hungry, man. Hungry to get into medical school and now they are clicking the schools that in the past they didn't.

So yeah. Asking can you shadow a doctor in their office or in the hospital? Totally cool if you're in high school or you're an already high achieving college student. But for the person who hasn't been so serious all along? Don't bother. Following me or any other doctor around won't do much more than frustrate everyone.

Man. I feel so horrible for saying all of this. But it's true. Someone needs to yell it, scream it, tell it--it's true. And see, we need to either figure out how to re-humanize the application process or get the word out to everyone that there is no goof-off margin any more in college for those who wish to go to medical school. Additionally, even if you didn't goof off, unless you go hard from the very start academically, no one will ever get a chance to see your great qualities beyond that. It's jacked up but it's true.

So anyone with a kid starting college or who just got there that wants to go to professional school? Here's my PSA: Go hard from day ONE. Make connections. You must be exceptional in person and on paper. Or at least make enough meaningful connections with people who can advocate for you enough to get your application in front of someone who'll actually read it should it fall below the bar. But remember that, even with connections and prayers, being "just above average" academically could get you shut out of what you aspire to do.

And you know what? You won't even be able to take it personally. Because it won't be personal. In fact, it won't be personal at all. Nope.

Oh--and before someone says it--yes, I know that there is a story of someone somewhere after 1991 who overcame all of this and got into the very best med school in the whole world and did great. Just like someone somewhere dropped a quarter into a slot machine and won a million dollars. Just consider this some pragmatic real talk. And the earlier it reaches the right people, the better.

Yeah. I need to get this message out man. Because it ain't 1991 anymore. No ma'am and no sir.

Thanks for letting me ramble on this. I mean it. Oh, and sorry for the buzz kill.


***
Happy Sunday. And Happy New Year, too.

I should tell you.

exactly when is it a good time
to ruin your life?

or rather

life as you know it?

the one filled with hurdles, yes
but still that far away uncertainty
that we all share when it comes to embracing
the inescapable fate that we all must someday face?

death

when might you suggest
I bring up these facts that I am holding close to my chest?

the ones that will snatch you from your loved ones
like a ruthless thief
and pry you away from your future hopes and dreams?

is now a good time?
or would you prefer I come back later?
tv muted or off?
lights on or would sunlight somehow make it feel 
less awful 
and unnatural?
shall I tell you on an empty stomach?
or a full one instead?
or not bother with any of these trivial things
and jump right in and tell it all?

your life is about to change
and just maybe--
no more than maybe--
end

tell me
would offering you a blissful weekend 
before you walk into your new normal be better?
would offering you that be empathic?
or unethical?
or cruel?

or what?

I'm asking you
because I don't know
I don't

and yes, I do know
that I should tell you
and that I must tell you
but I also should tell you
that I've seen people wade those waters
not just the ones like you
but the ones who love the ones like you

but I know I should tell you
but when? 
when would you recommend
that I shatter your world?

after I speak 
the tranquil sea of your life will split
one half will be B.C. -- before cancer
and everything else consumed by the deafening white noise
of A.D.--after diagnosis.

and no

this isn't the kind that can be knocked into remission
with good family support
or aggressive drug regimens
or fancy juicing machines

nope

it's the kind that you see
and then say
"damn"
about

damn

damn
because I know I should tell you
of course I know I should tell you
but please tell me, what time is best?
what might you suggest?

'cause see I keep asking myself
and my answer is never

never

even though I should tell you
that it can't be that

*** 

Now playing on my mental iPod. . . . 

)

Beyond pleasantries.

He spoke in those ways that doctors like; those ways that make our job easier. Sitting all the way upright in bed, wide and relaxed smile on his face and eyes on our team and not Judge Judy blaring over his head. And I could tell that, because of this, he stole the hearts of my students and residents. That part I knew for sure because he'd stolen mine, too.

With every word, a sure nod of his head accompanied. Unsolicited compliments came from him about the bedside manner of his student doctor. She blushed quickly; it was endearing.

We were there to see him about his hospitalization for something serious. The diagnosis was one of those ones you don't wish on even an enemy and, as of this encounter in the hospital, the list of options for medical interventions had officially run out. So this, his pleasant demeanor and dancing eyes, we welcomed. We weren't contending with fear or anger or any of those other sticky things that often set up road blocks to patient care.

At least it didn't seem that way.

"What is your understanding of why you're here?" I asked. We were in a semicircle around his bed on rounds. The student caring for him on his left and me, on his right. He swung his head from side to side when speaking. Ever-inclusive of that student. Ever-pleasant which we all appreciated.

"Well," he said, "my student doctor here said it's swelling in my brain. I also saw another doctor--and he was REAL, REAL GOOD--and he say he don't think I need no more chemos or radiation. And I said, okay! Just do what you gotta do! Whatever y'all think!"

"I see."

"Yep. So now I'm getting some medicine for the swelling."

"That's right, sir. Can you tell me why you have the swelling?"

"Because of some cells, they tell me. Cells all together making some tumors. But the cells got some swelling on 'em."

"Gotcha."

And after he said that, he smiled even bigger. He turned his head to face his student doctor and nodded again. He wanted her approval.

This mostly seemed fine. But, see, I'd been doing this long enough to notice how vanilla these answers were. And I know how easy it is to get lost in pleasantries, especially during difficult discussions.

I asked a few more questions but in different words. I needed to know whether or not he realized what was going on. What it meant for someone to say "no more chemos or radiation" and exactly what that meant from a big picture perspective. So through my questions I tried my best to excavate the truth.

Was he afraid but aware?
Did he lack insight?
Was the pleasantry a mask that hid some early dementia?
Or was he simply a nice guy with a bad, bad disease?
Or worse, was it all of these?

Turns out it was. It was all of those things.

A little afraid. And seemingly aware that anything causing someone to be called to come get admitted is serious. He was right about that. His insight was poor about just how serious, though. He didn't seem to recognize that these were usually talks that open the door to ones about hospice and end-of-life care. Even though, according to the hospital chart, that REAL, REAL GOOD doctor he'd seen earlier had tried to explain this.

We proved that some of this he couldn't grab because of cognitive dysfunction. I asked his student doctor to come back and perform a mental status examination on him. The intern caring for him with that student seemed surprised by that request, but they obliged. He, too, got lost in the pleasantry and didn't see the need to question his cognitive ability. That test confirmed what had perhaps been missed before--a dementia component. Or maybe not missed but, from what I could see, not discussed. And that part would muddy up the full explanation part and likely had for some time.

So, in the end, all of this made it harder. That and the fact that there was no denying that, indeed, he was simply a nice guy with a bad, bad disease. A bad disease that he doesn't understand.

***

Duty Hours Pre-Form Part 3: Panic! At the NICU.

*Names and details changed to protect anonymity. . . you know the deal. . .

image credit - premature baby in NICU

By the time I reached my final year of residency, very little scared me.  As a fourth year veteran in a combined Internal Medicine and Pediatrics residency, I had faced my share of medical emergencies and had weathered some substantial storms.  My training took place in the 90's, so none of this medical experience was limited or abbreviated by the need to scurry out of the hospital to adhere to duty hours restrictions.  So by that last year? Chile, please.  My motto was (with a dust of my shoulders) "Bring it on."

Every three months we alternated between rotations in the Pediatrics department and the department of Medicine. In the first two years of training, those "switch months" were terrifying. As an intern, that first change over in October landed you squarely in a foreign land, kind of like a new kid in school that started three months late.  You'd be asking dumb questions about fluids in infants or trying to calculate dosages per kilo in 175 pound adults.  Not cool.  The second year was tricky, too, because it was punctuated by a belated introduction into the supervisory role.  All of your classmates in the un-combined programs had already gotten a six month jump on you, so here you were fumbling with finding your mojo as your interns gave you a hairy eyeball. It was just as rough as it sounds.

But then came fourth year. That glorious fourth year.  You were now the "super senior" and big man/woman on campus. . . the person they woke up late at night to get the impossible procedures . . .the one that incited cheers from trembling interns when they discovered that it would be you bringing all of your mojo to their night on call.  Yeah, baby.

One night in the late fall during my fourth year, I was the senior resident on call in the neonatal intensive care unit (NICU.)  The NICU at this particular hospital was a level III which meant that, with the exception of complicated surgical needs, most of the medically complex babies born at our facility stayed right there. There was no life flight helicopters to rescue us from the sickest of the sick or the tiniest of the premature.  And although I said that very little scared me by this point, a rough night in the NICU was the one thing that absolutely did. Scared the absolute crap out of me.

Babies. There's just something about babies that haven't lived their lives yet and the parents who are counting on you to do everything that always kept butterflies in my stomach all night long whenever I was there. We carried this pager called the "code pink" pager when we were on call. No, it wasn't pink or anything, but it did scream like a banshee whenever some mama was delivering a baby with any inkling of a potential complication.

Most times it was simple stuff. The cesarean sections were the easiest of all -- baby with a big head that wouldn't pass through mama's narrow pelvis. C-sections always got us called just to be on the safe side. Fortunately, all that meant was chuckles with the anesthesia team, smiles with the nurses and coos at the new baby who'd just been lifted out of a bikini incision.  My favorite part was seeing the mama's face when someone showed her the baby.  I liked being that someone, so usually leaped at the chance to swaddle the little pumpkin and whisk it over to the other side of the blue curtain as the proud papa smiled too.

The meconium-stained amniotic fluid calls were more complicated. You could arrive to a baby in major respiratory distress or find a bouncing baby with nothing but stained finger nails. Meconium is the fancy name for the poo that the fetus is supposed to hold until after the big arrival.  If the baby is under some stress, like infection or some issue with mama's health, they let it go in utero. When the water breaks, that greenish fluid signals the OB to call us for back up--and to get that baby out of there quick.

Then there were the premature deliveries. Those dear, dear mothers sitting in bed strapped to a monitor and praying to God that the baby wouldn't come out.  In these cases, we would follow our attending and fellow into the room and speak with the mom about what to expect. Mom would get steroids to help the baby's lungs to speed up at maturing while the high risk OB team would do all they could to keep the fetus in mom as long as possible. But in the times where the delivery was inevitable, for the most part we were ready.  Ventilators and infant warmers rearing to go and bad ass NICU nurses ready to pounce on that baby until it was medically copastetic.

This night we'd hustled over to a few c-sections and one or two meconium fluid deliveries. At least one of those babies had some complications, so it required us to put in lines and figure out the ventilator settings. We got that baby stabilized and later we admitted a 29 1/2 week preemie that, other than being a little on the small side, was doing fabulous. Combine this with the babies already in the NICU and our hands were full. Even though all of these things had us hopping, for the most part, it wasn't too bad of a night. And even better, the neonatal ICU fellow on call with me--Shanthi--was one that I trusted. She was smart and organized and not the the least bit lazy. All was well with the world. Especially since I had her with me in the one place in the hospital that challenged my sphincter control.

It was after midnight and finally things were slowing down in the unit. "Let's get some sleep while the getting is good," said Shanthi in her melodic Indian-slash-British-tinged accent. "You guys go to bed."

"No, Shanthi, I'll stay in here and crash in this recliner chair out here. Besides, you know the nurses call the resident for the minor things not you. Here--give me the call pager." I wiggled my fingers and opened my palm. "No worries. I'll call you if something's up, alright?"

She paused for a moment and then it registered. I was a fourth year. A super-duper pre-chief residency senior, no less. She smiled in acknowledgment and unclipped the pager from her hip.  Before I knew it, she and the intern had disappeared into the call rooms. I kicked off my clogs and hoped no one could smell the sweaty call-night feet that immediately wafted up toward my nose. I thought about putting them back on, but before I could I fell fast asleep in a snap.

I have no idea how long I was sleeping. I know it was long enough to feel good and short enough to not want it to end. Like always, at first I dreamed about placing arterial lines with 24 gauge needles and remembering the steps to neonatal resuscitation. Then I'd float off into some other magical place with no pagers and no post call clinics. . . . .

First came the sirens on the pager. Then came the voice of the operator blaring through the tiny device:

"CODE PINK! CODE PINK! EMERGENCY DEPARTMENT! UNKNOWN DATES!  CODE PINK! CODE PINK! EMERGENCY DEPARTMENT SIDE A! UNKNOWN DATES!"


Unknown dates?!? Crap!

"Unknown dates" was the worst. It was the most like Russian roulette of all the NICU situations in my opinion. There was no way to predict what you'd get. Either it would be an unfortunate teen who'd concealed a term pregnancy from her (also unfortunate) folks with basically no complications or a very early delivery that came so fast that there was no time to get a history.  The latter these two was a bullet straight to the brain. And unknown dates in the EMERGENCY department? That was the nail in the coffin.

Before I knew it, my stinky feet were stuffed into those clogs and I was off running like Flo-Jo toward the ED.  I could scarcely hear the NICU nurses -- one running steps a few steps behind me and another getting an infant warmer ready.

Once I pushed open the heavy door leading to the stairwell and made it down a couple of flights of steps, it dawned on me. I was the only doctor running. I knew Shanthi had been working so many wretched hours when I made a rookie mistake--taking the code pagers and assuming nothing could go wrong. Normally, she would have never agreed to such a thing. She was too responsible for that. But Shanthi was a second year NICU fellow and I was a fourth year Med/Peds resident. Technically, we were only one year apart in our training so she gladly bit when I offered. Plus she was so physically and mentally exhausted that her body melted at a chance to sleep perchance to dream.

Once I reached the corridor heading to the ED, the reality of what I might find began to press on me like some oppressive weight. I started reflexively praying for it to be nothing serious. I felt a tiny bit relieved when Olivia, one of the most bad-ass NICU nurses ever (wait, are there any other types of ICU nurses?) came jogging up beside me.

"Any clue about this mom?" she said.

"None at all," I replied still panting and heart feeling like it would jump out of my chest.

"Where's Shanthi?" Olivia queried with widened eyes.

I could feel the panic rising up in my throat as we neared the A side of the ED. "I have the code pagers. Shit, Olivia. I need someone to call her once we see what's up."

"NICU TEAM!" we both announced to the crowd of Emergency Department faculty and residents surrounding the patient. The crowd parted like the Red Sea to let us in. One of my buddies who was a senior ER trainee was gowned and gloved, prepared to catch the baby. She nodded in my direction and I returned the favor. An OB/Gyn resident was quickly getting ready to take her place at the foot of the bed.

I surveyed the setting. This mother was no teen. She looked to be in her mid-thirties and my chest started immediately hurting when I saw the tears squeezing out of the sides of her eyes. A tiny gold band on her left finger caught my attention. I didn't see her husband, but this did not look like what she had in mind at all.

"21 to 23 weeks according to dates. Prenatal care out of state. Here visiting a friend for the weekend. Water broke and started contracting and dilating. She's been given magnesium already but she's dilating and completely effaced." My ER friend was all business when she told me the little history she knew. Her voice was steady and staccato and she spoke like it was into a radio and not in earshot of the pregnant mother. It was a lot to take in.


"Shit." I realized I'd said this out loud but honestly? So much chaos was going on in there that my one expletive paled in comparison to the others flying around.  In came two more NICU nurses, Jasmine and Alice with the infant warmer and Marge the respiratory therapist extraordinaire preparing themselves for the delivery.  Marge hands me a pair of sterile gloves, a size 0 laryngoscope, and quickly began attaching things for an imminent intubation.  I had intubated many many babies by this point, but unknown dates always freaked me out.  I followed what I'd been taught and stood ready to secure an airway for this likely very premature baby. My heart was already pounding in my chest; I was sure anyone nearby could not only hear it but see it lifting my shirt off of my chest.

Because, see,  there was something else to all of this. Those gestational dates. 21 to 22 weeks. Somewhere in the gray zone for viability and a not gray zone at all for medical complications. Shit, shit, shit.  I looked around to see if somebody had called Shanthi but no such luck. Everything after that happened in slow motion.

The OB resident couldn't even get into place before this extremely premature baby came sliding out into the sterile gloves of the ER resident. More of those tears squeezed from the mother's eyes and the minute I saw that baby, I swear I wanted to do the same thing. She couldn't have been more than 22 weeks. A gelatinous little angel with skin as transparent as Saran wrap, fused eyelids, and the tiniest human chest I'd ever seen pulling hard over even tinier lungs for air. Her swollen genitals made me pause for moment before affirming that it was indeed a girl. An extremely premature girl. They positioned the infant right in front of me. . . all I needed to do was intubate.

My heart and hand froze for a split second as I looked at this sweet, sweet baby. . .pulled out of the oven waaaay before she was fully baked. Shit. I didn't want to be a part of this. I felt like I was going to suffocate from the fear and also from all of the people moving around me. Shit. She was no bigger than the center of my palm. This was crazy. Damn, this baby wasn't ready to be here. She wasn't. I glanced once more at her already grieving mama. Grieving the normal new mama life that she had envisioned and trembling with fear at what this new reality would be. Water broke. Out of town. No birthing plan or funky reggae music blaring in the delivery room. No husband coaching or grandmothers squealing in delight. Shit.  Once more I looked at her baby--all of this taking place over the course of a second--and something in my head questioned whether a resuscitation in a neonate this premature was even ethical.  I wasn't sure -- which to me was instinctively telling.

But there wasn't time for all that. Before I could even think further the scope was in her minuscule mouth and my eyes were fixed on her bleating pink vocal cords. Marge placed the endotracheal tube squarely in my hand and in the blink of an eye she was connected to a ventilator and off we went to the unit. Whether her mother liked it or not.

Shanthi met us the minute we stepped off of the elevators. "Jesus, Kim!" she gasped incredulously while staring at the baby and helping push the rolling warmer, "Heavens. What were the dates again?" She was saying the first thing that came to her mind when seeing this terrifyingly small newborn. I didn't blame her.

"22 weeks?" I answered flatly. Shanthi raised her eyebrows at me. "Okay. Maybe 21 and a half? I don't know. There was no history." I felt my lip quivering and quickly bit down on it.

21 and a half weeks. But what was I supposed to do? Say no right then and there? Shut the whole operation down and be the horrible devil that gave up hope? I knew this was complicated, I did. But something told me that doing everything wasn't necessarily the best option. Especially since the mom wasn't in on it all. This sucked. Royally. Shanthi knew that so she backed off.

The baby was here and alive and under our care so we leaped into action. In went the lines in her umbilical vein and artery. Every few seconds we checked the results of the blood gases sent to assess ventilatory status.  Baby P.  We worked on Baby P until the morning teams came in.

Shanthi and I spoke to Baby P's mom early that morning. Eyes bloodshot, body haggard and now with feet so sweaty and dog tired that I could smell them straight through my clogs without them even being off.  I did my best to explain what had gone on to Baby P's mom, and learned that morning that baby P was a little under 21 1/2 weeks gestation.  Shit. This was mom's first pregnancy and things had been going well. Turns out she had something called cervical insufficiency--where the cervix can't hold the baby inside once it reaches a certain size and weight. Most moms don't know they have this problem until it's too late.  Fortunately, the next time around (if there is one) mom can have her cervix secured surgically with a cerclage.

But now her extremely premature baby daughter was here. And just like me in that ER, what was she supposed to do? Give up on her first and potentially only baby? Hadn't we given her a promise that this could all work out okay since we went full guns blazing to keep her alive? Yes. She was here. Intubated and filled with tubes, fighting for her life.

Since I admitted Baby P, I was the primary resident caring for her. My attending that month was a hard core NICU guy and never even considered backing off with our heroic efforts once we learned that she was less than 22 weeks. Nope. That ship had sailed already.

Baby P lived nearly nine days. Her brief life was tortured, the majority of which was at my own hands.  She fought horrible infections, coded nearly every day, only to be brought back to life for a few more moments. Her brain bled two times and her little body seized repeatedly. Every single day that I cared for her, I'd steal away to sit in the call room or a stair well to cry. Trembling into my hands and apologizing repeatedly to Baby P and her parents quietly in the dark. Praying in simple language and feeling on the brink of nausea. Trying to forgive myself for intubating her that day and wishing I'd had the courage not to...or to at least present "nothing" as an option.

Two calls later, Baby P's heart stopped beating. Just like that. This time, following the parents' wishes, we didn't code her. Instead we all enveloped the parents in a giant, exhausted group hug. All of us weeping for reasons that you'd have to ask each individual to explain, but weeping all the same and not even trying to hold it back.  Me, the NICU nurses, Shanthi, and Marge huddled around the parents as they finally--for the first time in 8 days--got to hold their baby daughter. It was awful.

What had we done? What had I done?

I had to get out of there. I remember running out of the NICU. Past the nurses' station and past the waiting areas. Down the hall into the corridor. Just running and running. Out. I had to get out of there. I needed air. I needed out. I got outside and paced in the biting Cleveland autumn air. I folded my arms hard over my bare arms and tried to ignore the chill climbing into my scrub pants.  I felt like I had fought against God and against nature and lost. And whether you believe in God or nature or both, fighting them just feels inherently wrong. Unsettling and wrong.

Those 8 1/2 days haunted me for a long time. In fact, I cried while writing this because I could see those fused eyelids and air-hungry chest like it was yesterday.  All over again, I wished I had been with my fellow and not alone. I know that she would have put her foot down. I believe that. And smug me-- thinking our one year apart was no big deal-- learned a huge lesson that night. It WAS a big deal. A huge one. And yes, I realize that some 21+ weeker baby born under similar circumstances somewhere has a testimony and THEY made it and are alive and "just fine." I am sure that baby exists, but I also know that there are several others who don't have that testimony. Or they made it alive but no one would describe the outcome as "just fine." Not one bit. My guess is that those individuals might be easier to find than the former.

Medical training is wonderful and horrible. A lot of the decisions that get made are quick calls from one person, and they can change everything. Experience plays a big role in how ready you are to make those calls and that day, I needed back up.

At the end of that month, I asked Shanthi how she felt about Baby P and what had transpired. She began weeping and saying she was sorry for leaving me that night. She said she never should have let me take her pager. She was the NICU fellow in house. Not me.

"Would you have resuscitated her?" I had to know.

Shanthi looked down at her fingernails and sighed.  Finally she locked eyes with me and shook her head no. I swallowed hard and tried to fight the hot tears that began rolling down my cheeks as I nodded in agreement. I knew that answer before I even asked.

Things have changed since then. Now, a level III NICU is staffed with board-certified neonatal intensivists overnight. With enough experience to feel more confident in their judgment calls than I was as a resident. And when you're talking about little babies in very high stakes situations, that's probably how it should be. At least that's what I think.

The moral of this? I don't know. I guess I just needed to get the story out. Because medicine? Medicine is some serious shit.

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Now playing on my mental iPod. . . . "Ready to Go" from Panic! at the Disco.